Medical History Patient Name First Last Age Name of Physician/and their specialtyMost recent physical examination PurposeWhat is your estimate of your general health?ExcellentGoodFairPoorDO YOU HAVE or HAVE YOU EVER HAD:hospitalization for illness or injuryYesNoan allergic reaction toYesNoAllergies aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride nickel gold silver latex other Please state otherheart problems, or cardiac stent within the last six monthsYesNoIf Yes, please list which onehistory of infective endocarditisYesNoartificial heart valve, repaired heart defect (PFO)YesNopacemaker or implantable defibrillatorYesNoorthopedic implant (joint replacement)YesNoIf Yes, Which Jointrheumatic or scarlet feverYesNohigh blood pressureYesNoLow blood pressureYesNoa stroke (taking blood thinners)YesNoanemia or other blood disorderYesNoIf Yes, please list which oneprolonged bleeding due to a slight cut (INR > 3.5)YesNoemphysema, shortness of breath, sarcoidosisYesNotuberculosisYesNoMeaslesYesNoChicken poxYesNoasthmaYesNobreathing or sleep problems (i.e. sleep apnea, snoring, sinus)YesNokidney diseaseYesNoliver diseaseYesNojaundiceYesNothyroid, parathyroid disease, or calcium deficiencyYesNohormone deficiencyYesNohigh cholesterol or taking statin drugsYesNodiabetesYesNoHbA1c =stomach or duodenal ulcerYesNodigestive disorders (i.e. celiac disease, gastric reflux)YesNoIf Yes, please list which oneosteoporosis/osteopenia (i.e. taking bisphosphonates)YesNoarthritisYesNoautoimmune disease(i.e. rheumatoid arthritis, lupus, scleroderma)YesNoglaucomaYesNocontact lensesYesNohead or neck injuriesYesNoepilepsy, convulsions (seizures)YesNoneurologic disorders (ADD/ADHD, prion disease)YesNoIf Yes, please list which oneviral infections and cold soresYesNoany lumps or swelling in the mouthYesNohives, skin rash, hay feverYesNoIf Yes, please list which oneSTI / STD / HPVYesNoIf Yes, please list which onehepatitisYesNohepatitis typeHIV / AIDSYesNotumor, abnormal growthYesNoradiation therapyYesNochemotherapy, immunosuppressive medicationYesNoemotional difficultiesYesNopsychiatric treatmentYesNoantidepressant medicationYesNoalcohol / recreational drug useYesNoARE YOU:presently being treated for any other illnessYesNoaware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)YesNotaking medication for weight managementYesNotaking dietary supplementsYesNooften exhausted or fatiguedYesNoexperiencing frequent headachesYesNoa smoker, smoked previously or use smokeless tobaccoYesNoconsidered a touchy / sensitive personYesNooften unhappy or depressedYesNotaking birth control pillsYesNocurrently pregnantYesNoprostate disordersYesNoDescribe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)List all medications, supplements, and or vitamins taken within the last two years.Drug and there purposePLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
